Design to Improve Visibility: Impact of Corridor Width and Unit Shape

Visibility-based layout of a hospital unit - An optimization approach

A patient fall is one of the adverse events in an inpatient unit of a hospital that can lead to disability and/or mortality. The medical literature suggests that increased visibility of patients by unit nurses is essential to improve patient monitoring and, in turn, reduce falls. However, such research has been descriptive in nature and does not provide an understanding of the characteristics of an optimal inpatient unit layout from a visibility-standpoint. To fill this gap, we adopt an interdisciplinary approach that combines the human field of view with facility layout design approaches. Specifically, we propose a bi-objective optimization model that jointly determines the optimal (i) location of a nurse in a nursing station and (ii) orientation of a patient's bed in a room for a given layout. The two objectives are maximizing the total visibility of all patients across patient rooms and minimizing inequity in visibility among those patients. We consider three different layout types, L-shaped, I-shaped, and Radial; these shapes exhibit the section of an inpatient unit that a nurse oversees. To estimate visibility, we employ the ray casting algorithm to quantify the visible target in a room when viewed by the nurse from the nursing station. The algorithm considers nurses' horizontal visual field and their depth of vision. Owing to the difficulty in solving the bi-objective model, we also propose a Multi-Objective Particle Swarm Optimization (MOPSO) heuristic to find (near) optimal solutions. Our findings suggest that the Radial layout appears to outperform the other two layouts in terms of the visibility-based objectives. We found that with a Radial layout, there can be an improvement of up to 50% in equity measure compared to an I-shaped layout. Similar improvements were observed when compared to the L-shaped layout as well. Further, the position of the patient's bed plays a role in maximizing the visibility of the patient's room. Insights from our work will enable understanding and quantifying the relationship between a physical layout and the corresponding provider-to-patient visibility to reduce adverse events.

Supportive or Hindering Physical Environments in Hospital Units Dealing With COVID-19 Patients

PURPOSE

This project was designed to discover how hospital units with COVID-19 patients influenced staff's medical practices and health conditions.

BACKGROUND

Although hospital environments have well-known associations with health outcomes, findings are limited in demonstrating the role of physical environments during a global pandemic.

METHODS

A cross-sectional survey study was conducted from three units in a university hospital and a total of 113 staff participated. They rated the impact of physical environments on staff members' medical practice and their health conditions before and mid-pandemic. They also specified physical changes, hindering and helpful features, and future improvements in open-ended questions.

RESULTS

The perceived supportiveness of the physical environments on communication significantly dropped from before-pandemic to midpandemic, followed by mental health and feeling of connection and engagement. Separating COVID-19 patients helped staff workflow, but staff felt disconnected and had poor visibility.

CONCLUSION

Based on painful lessons, interdisciplinary researchers, including healthcare professionals, designers, and administrators, should further collaborate to create supportive hospital environments.

Measuring Potential Visual Exposure of Physicians During Shift-End Handoffs and Its Impact on Interruptions, Privacy, and Collaboration

BACKGROUND

Frequent interruptions, inadequate privacy, and lack of collaboration are barriers to safe and efficient end-of-shift handoffs between emergency physicians. Varying levels of visibility to and from physicians can impact these outcomes. This study quantifies potential visual exposure of physicians in workstations with varying enclosure levels using isovist connectivity (IC) as a measure. Further, this study examines the association of IC with number of interruptions/hour, perceived collaboration, and privacy during handoffs.

METHODS

In-person observations were conducted during 60 handoffs to capture interruptions. Surveys were administered to the incoming and outgoing physicians to garner their perceptions of the extent of interruptions, collaboration, and privacy. Spatial analysis was conducted using DepthmapX.

RESULTS

Findings demonstrate significant differences in IC scores based on (a) physicians location within the workstation during; (b) handoff approach (individual or collaborative); (c) position during handoff (sitting or standing). Documented interruptions were highest in the high IC locations and lowest in the medium and low IC locations. Physicians in low IC locations perceived to have sufficient privacy to conduct handoffs.

LIMITATIONS AND CONCLUSION

It should be noted that the three pods, each housing a physician workstation with different enclosure levels, varied in number of patient rooms, patient acuity, overall size, and the location of workstations. While contextual variables were considered to the extent possible, several other factors could have resulted in differences in number of interruptions and collaboration levels. This study provides design recommendations for handoff locations and a method to test emergency physician workstation designs prior to construction.

Investigating the role of spatial configuration on visitors’ spatial cognition in health-care spaces: case studies in Gilan, Iran

Purpose

This study aims to explore the impact of spatial configuration on behavioral patterns of visitors in the ground floor of health-care spaces.

Design/methodology/approach

In this study, the Space Syntax analysis was used to combine visibility graph analysis and axial line analysis with empirical observation of visitors’ activities. Two types of observation methods on visitors were conducted to discover the behavioral patterns of individuals, respectively, named “gate counts” and “people following.”

Findings

The outcomes of this research revealed that the spatial arrangements of pathways, public areas, vertical circulations, entrance space, lobby, emergency department, reception desk and pharmacy have a significant influence on the way that visitors perceive the health-care environment.

Research limitations/implications

The current research is limited to two aspects of effective wayfinding (configuration of health care and geometry). Future work can investigate the other potential factors coupled with the current factor as an integrated research for enhancing wayfinding and sustaining accessibility. Another limitation is that the observation results for this study had been conducted before the COVID-19 pandemic and future studies can compare these results with the current COVID-19 situation within health care environments.

Originality/value

A large amount of research has focused on the needs of populations in developed countries. This topic has not been investigated thoroughly by professionals in developing countries such as Iran. Accordingly, this study benefits environmental psychologists and architects by revealing the effective characteristics of legible spaces in health-care environments.

Study on Collision Detection Techniques for the Informed Design of Natural Views in Healthcare Environments

BACKGROUND

Natural views are an important design strategy for the application of ecological resources in built environments. Numerous clinical studies have indicated that views of nature-for example, plants-can effectively promote patient recovery by relieving their postoperative pains and negative emotions during hospitalization.

AIMS

This study demonstrates an intelligent method that develops algorithms of using collision detection techniques in Building Information Modeling to evaluate outdoor plant visibility for patients.

METHODS

These algorithms are digitized into a Revit plug-in program, which can be viewed as a design-aided tool for architects with the purpose of informing healthcare environment design in the decision-making process.

RESULTS

Its acceptability and effectiveness are evaluated based on the consultations in beta tests.

CONCLUSIONS

It is believed that this method can improve the work efficiency of evaluating natural views in wards and help architects implement an informed design of built environments for better health performance. All findings in this study can contribute to the development of computational intelligence and social sustainability in the near future.

The HDR CARE Scale, Inpatient Version: A validated survey instrument to measure environmental affordance for nursing tasks in inpatient healthcare settings

Rigorous healthcare design research is critical to inform design decisions that improve human experience. Current limitations in the field include a lack of consistent and valid measures that provide feedback about the role of the built environment in producing desirable outcomes. Research findings about nurses’ efficiency, quality of care, and satisfaction related to inpatient unit designs have been mixed, and there was previously no validated instrument available to quantitatively measure nurses’ ability to work efficiently and effectively in their environment. The objective of this study was to develop, refine, and validate a survey instrument to measure affordance of the care environment to nurse practice, based on various aspects of their work in inpatient units. The HDR Clinical Activities Related to the Environment (CARE) Scale Inpatient Version was developed using item design, refinement, and reliability and validity testing. Psychometric methods from classical test theory and item response theory, along with statistical analyses involving correlations and factor analysis, and thematic summaries of qualitative data were conducted. The four-phase process included (1) an initial pilot study, (2) a content validation survey, (3) cognitive interviews, and (4) a final pilot study. Results from the first three phases of analysis were combined to inform survey scale revisions before the second pilot survey, such as a reduction in the number and rewording of response options, and refinement of scale items. The updated 9-item scale showed excellent internal consistency and improved response distribution and discrimination. The factor analysis revealed a unidimensional measure of nurse practice, as well as potential subscales related to integration, efficiency, and patient care. Within the healthcare design industry, this scale is much needed to generate quantitative and standardized data and will facilitate greater understanding about the aspects of an inpatient healthcare facility that best support nurses’ ability to provide quality patient care.

Why hospital design matters: A narrative review of built environments research relevant to stroke care

Healthcare facilities are among the most expensive buildings to construct, maintain, and operate. How building design can best support healthcare services, staff, and patients is important to consider. In this narrative review, we outline why the healthcare environment matters and describe areas of research focus and current built environment evidence that supports healthcare in general and stroke care in particular. Ward configuration, corridor design, and staff station placements can all impact care provision, staff and patient behavior. Contrary to many new ward design approaches, single-bed rooms are neither uniformly favored, nor strongly evidence-based, for people with stroke. Green spaces are important both for staff (helping to reduce stress and errors), patients and relatives, although access to, and awareness of, these and other communal spaces is often poor. Built environment research specific to stroke is limited but increasing, and we highlight emerging collaborative multistakeholder partnerships (Living Labs) contributing to this evidence base. We believe that involving engaged and informed clinicians in design and research will help shape better hospitals of the future.

Intensive Care Unit Built Environments: A Comprehensive Literature Review (2005-2020)

BACKGROUND

The intensive care environment in hospitals has been the subject of significant empirical and qualitative research in the 2005-2020 period. Particular attention has been devoted to the role of infection control, family engagement, staff performance, and the built environment ramifications of the recent COVID-19 global pandemic. A comprehensive review of this literature is reported summarizing recent advancements in this rapidly expanding body of knowledge.

PURPOSE AND AIM

This comprehensive review conceptually structures the recent medical intensive care literature to provide conceptual clarity and identify current priorities and future evidence-based research and design priorities.

METHOD AND RESULT

Each source reviewed was classified as one of the five types-opinion pieces/essays, cross-sectional empirical investigations, nonrandomized comparative investigations, randomized studies, and policy review essays-and into nine content categories: nature engagement and outdoor views; family accommodations; intensive care unit (ICU), neonatal ICU, and pediatric ICU spatial configuration and amenity; noise considerations; artificial and natural lighting; patient safety and infection control; portable critical care field hospitals and disaster mitigation facilities including COVID-19; ecological sustainability; and recent planning and design trends and prognostications.

CONCLUSIONS

Among the findings embodied in the 135 literature sources reviewed, single-bed ICU rooms have increasingly become the norm; family engagement in the ICU experience has increased; acknowledgment of the therapeutic role of staff amenities; exposure to nature, view, and natural daylight has increased; the importance of ecological sustainability; and pandemic concerns have increased significantly in the wake of the coronavirus pandemic. Discussion of the results of this comprehensive review includes topics noticeably overlooked or underinvestigated in the 2005-2020 period and priorities for future research.

Influences of Physical Layout and Space on Patient Safety and Communication in Ambulatory Oncology Practices: A Multisite, Mixed Method Investigation

OBJECTIVE

To examine how physical layouts and space in ambulatory oncology practices influence patient safety and clinician communication.

BACKGROUND

Ambulatory oncology practices face unique challenges in delivering safe care. With increasing patient volumes, these settings require additional attention to support patient safety and efficient clinical work processes.

METHODS

This study used a mixed methods design with sequential data collection. Eight ambulatory oncology practices (of 29 participating practices) participated in both the quantitative and qualitative phases. In surveys, clinicians (n = 56) reported on safety organizing and communication satisfaction measures. Qualitative data included observations and semistructured interviews (n = 46) with insight into how physical layout influenced care delivery. Quantitative analysis of survey data included descriptive and correlational statistics. Qualitative analysis used inductive and thematic content analysis. Quantitative and qualitative data were integrated using side-by-side comparison tables for thematic analysis.

RESULTS

Safety organizing performance was positively correlated with clinician communication satisfaction, r(54 df) = .414, p = .002. Qualitative analyses affirmed that the physical layout affected communication around chemotherapy infusion and ultimately patient safety. After data integration, safety organizing and clinician communication were represented by two themes: visibility of patients during infusion and the proximity of clinicians in the infusion center to clinicians in the clinic where providers see patients.

CONCLUSIONS

Physical layouts of ambulatory oncology practices are an important factor to promote patient safety. Our findings inform efforts to construct new and modify existing infusion centers to enhance patient safety and clinician communication.

Telemedicine Implementation in COVID-19 ICU: Balancing Physical and Virtual Forms of Visibility

Objective:

This case study examines the implementation of inpatient telemedicine in COVID-19 intensive care units (ICUs) and explores the impact of shifting forms of visibility on the management of the unit, staff collaboration, and patient care.

Background:

The COVID-19 crisis drove healthcare institutions to rapidly develop new models of care based on integrating digital technologies for remote care with transformations in the hospital-built environment. The Sheba Medical Center in Israel created COVID-19 ICUs in an underground structure with an open-ward layout and telemedicine control rooms to remotely supervise, communicate, and support the operations in the contaminated zones. One unit had a physical visual connection between the control room and the contaminated zone through a window, while the other had only a virtual connection with digital technologies.

Methods:

The findings are based on semistructured interviews with Sheba medical staff, telemedicine companies, and the architectural design team and observations at the COVID-19 units during March–August 2020.

Results:

The case study illustrates the implications of virtual and physical visibility on the management of the unit, staff collaboration, and patient care. It demonstrates the correlations between patterns of visibility and the users’ sense of control, orientation in space, teamwork, safety, quality of care, and well-being.

Conclusions:

The case study demonstrates the limitations of current telemedicine technologies that were not designed for inpatient care to account for the spatial perception of the unit and the dynamic use of the space. It presents the potential of a hybrid model that balances virtual and physical forms of visibility and suggests directions for future research and development of inpatient telemedicine.

Advancing evidence-based healthcare facility design: a systematic literature review

Healthcare facility design is a complex process that brings together diverse stakeholders and ideally aligns operational, environmental, experiential, clinical, and organizational objectives. The challenges inherent in facility design arise from the dynamic and complex nature of healthcare itself, and the growing accountability to the quadruple aims of enhancing patient experience, improving population health, reducing costs, and improving staff work life. Many healthcare systems and design practitioners are adopting an evidence-based approach to facility design, defined broadly as basing decisions about the built environment on credible and rigorous research and linking facility design to quality outcomes. Studies focused on architectural options and concepts in the evidence-based design literature have largely employed observation, surveys, post-occupancy study, space syntax analysis, or have been retrospective in nature. Fewer studies have explored layout optimization frameworks, healthcare layout modeling, applications of artificial intelligence, and layout robustness. These operations research/operations management approaches are highly valuable methods to inform healthcare facility design process in its earliest stages and measure performance in quantitative terms, yet they are currently underutilized. A primary objective of this paper is to begin to bridge this gap. This systematic review summarizes 65 evidence-based research studies related to facility layout and planning concepts published from 2008 through 2018, and categorizes them by methodology, area of focus, typology, and metrics of interest. The review identifies gaps in the existing literature and proposes solutions to advance evidence-based healthcare facility design. This work is the first of its kind to review the facility design literature across the disciplines of evidence-based healthcare design research, healthcare systems engineering, and operations research/operations management. The review suggests areas for future study that will enhance evidence-based healthcare facility designs through the integration of operations research and management science methods.

Impacts of Nursing Unit Design on Visibility and Proximity and Its Influences on Communication, Privacy, and Efficiency

OBJECTIVES

This study examines the role of visibility and proximity on nurse communication patterns, perception of privacy, and efficiency in double-corridor nursing units.

BACKGROUND

Nurses are extremely important for the quality of healthcare. The literature suggests that visibility and proximity have a substantial impact on the delivery of care and staff experience. However, few studies have empirically examined nursing units in China.

METHOD

Questionnaire surveys, observations, and simulations of medication administration tasks were employed.

RESULTS

Visibility and proximity influenced communication patterns, perceptions of privacy, and efficiency. The type of wall in the medication room could impact nurses' perception of privacy and efficiency. A partial glass wall in the medication room could achieve balance between privacy and visibility. A medication room that is adjacent to and is easily accessed from the nurse station (NS) could provide efficient communication and efficient work. The partition type between the NS and the doctor's office and the layout of the medication room could impact communication patterns. The relative position of the NS, medication room, and disposal room could influence the flow of medication administration tasks, and a geographically contiguous spatial layout could enhance work efficiency.

CONCLUSIONS

The findings contribute to the body of knowledge on the impact of visibility and proximity on nurses' communication patterns, perception of privacy, and efficiency. Recommendations to improve the design of double-corridor nursing units are also provided.

Where We Walk Is What We See: Foundational Concepts and Analytical Techniques of Space Syntax

The most difficult issue in writing a methods paper on Space Syntax is that it is not simply a method. It is a theory on which a methodology has been built. In the 40 years since introduction, both its theory and its methods have advanced, including the creation and development of computerized software. Essentially Space Syntax investigates layouts, seen in plan drawings; but this is done from mature theoretical arguments about function in those spaces. While theories of society were at the genesis of Space Syntax, it has branched into cognition, transportation, economics, and so on, and has been used to investigate buildings, cities, and regions. In the last decade or so, Space Syntax has been used in different ways to investigate healthcare facilities. This article concentrates on explaining the analytical techniques of Space Syntax. The theoretical underpinnings are minimally described-just enough for the reader to understand the basis of the methods. All examples provided are based on the same hypothetical hospital floor layout for ease of comprehension and comparison. Also, all Space Syntax concepts are italicized for identification. Since the theoretical aspects are not treated in detail, the reader is advised to pay particular attention to the citations for advanced comprehension. This cannot be overemphasized.

A Systematic Literature Review of Empirical Studies on Decentralized Nursing Stations

Objectives:

The objective of this systematic review of literature was to critically evaluate peer-reviewed evidence regarding the effectiveness of decentralized nurse stations (DNSs).

Background:

The DNS has become an important topic in healthcare design research and practice over the past decade with aims of improving staff efficiency and patient experience. Research has shown to be inconclusive, with studies reporting an assortment of mixed findings.

Method:

A systematic review of literature was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses search process of electronic databases, citation tracking, and manual searches of references. All authors evaluated the studies independently. Studies included were empirical, peer-reviewed investigations of DNS in hospitals over the past 15 years. Each study was evaluated using an accepted healthcare design evaluation framework.

Results:

Over 200 studies were identified. After exclusions, 21 studies published since 2003 were available for full evaluation. Key findings from this review include (a) there is a positive trend toward patient experience in units with DNS, (b) nursing teamwork was perceived to decline in units with DNS, (c) methodological issues may be responsible for the mixed and inconsistent findings, and (d) there is no consistent categorization of nurse station typology or standard definition for DNS.

Conclusions:

Based on the evaluation framework, DNS are supportive of the patient experience yet have a negative impact on nursing teamwork. Higher quality studies are needed to classify specific typologies of DNS and account for elements such as patient care models, communication, visibility, and other patient care–related factors.

An Empirical Examination of Nursing Units in China Based on Nurse Experience

OBJECTIVES:

To create opportunities to increase nursing staff's satisfaction and operational efficiency and eventually improve nurses' experiences through better design in unit layout.

BACKGROUND:

The majority of research performed on nursing units in China only focused on the spatial design itself, and few studies examined the nursing unit empirically based on nurses' experience. Nursing units need to be designed with understanding nurses' behavior and experience in China.

METHOD:

A mixed-method approach was conducted in four double-corridor nursing units in China. Observation and interview data were collected to explore how physical environments for managing administrative duties, medications, and caring patient were used in nursing units.

RESULTS:

The most frequent activities were communication, medication, and patient-care activities. The places in which nurses spent the most of theirs working times were the nurse station (NS), patient room, workstation on wheels (WoW), and medication room. The important clinical work spaces were the patient room, NS, WoW, medication room, doctor's office, disposal room, examining room, and back corridor. The important traffic linkages were between NS and medication room, patient room and WoW, and medication room and patient room.

CONCLUSIONS:

This article revealed the frequency of nurse activities; how they spent their time; how they use the clinical spaces; identified important clinical spaces, linkages, and driver of inefficiency in nursing work and nursing unit design; and finally generated recommendations for double-corridor nursing unit design in China which can be used by medical planner, hospital administrator.

Nursing Unit Design, Nursing Staff Communication Networks, and Patient Falls: Are They Related?

Purpose:

The purpose of this research is to (1) investigate the impact of nursing unit design on nursing staff communication patterns and, ultimately, on patient falls in acute care nursing units; and (2) evaluate whether differences in fall rates, if found, were associated with the nursing unit physical structure (shape) or size.

Background:

Nursing staff communication and nursing unit design are frequently linked to patient safety outcomes, yet little is known about the impact of specific nursing unit designs on nursing communication patterns that might affect patient falls.

Method:

An exploratory longitudinal correlational design was used to measure nursing unit communication structures using social network analysis techniques. Data were collected 4 times over a 7-month period. Floor plans were used to determine nursing unit design. Fall rates were provided by hospital coordinators.

Results:

An analysis of covariance controlling for hospitals resulted in a statistically significant interaction of unit shape and size (number of beds). The interaction occurred when medium- and large-sized racetrack-shaped units intersected with medium- and large-sized cross-shaped units.

Conclusion:

The results suggest that nursing unit design shape impacts nursing communication patterns, and the interaction of shape and size may impact patient falls. How those communication patterns affect patient falls should be considered when planning hospital construction of nursing care units.

The Impact of Visibility on Teamwork, Collaborative Communication, and Security in Emergency Departments: An Exploratory Study

The aim of this study was to examine the influence of visibility on teamwork, collaborative communication, and security issues in emergency departments (EDs). This research explored whether with high visibility in EDs, teamwork and collaborative communication can be improved while the security issues will be reduced. Visibility has been regarded as a critical design consideration and can be directly and considerably impacted by ED's physical design. Teamwork is one of the major related operational outcomes of visibility and involves nurses, support staff, and physicians. The collaborative communication in an ED is another important factor in the process of care delivery and affects efficiency and safety. Furthermore, security is a behavioral factor in ED designs, which includes all types of safety including staff safety, patient safety, and the safety of visitors and family members. This qualitative study investigated the impact of visibility on teamwork, collaborative communication, and security issues in the ED. One-on-one interviews and on-site observation sessions were conducted in a community hospital. Corresponding data analysis was implemented by using computer plan analysis, observation and interview content, and theme analyses. The findings of this exploratory study provided a framework to identify visibility as an influential factor in ED design. High levels of visibility impact productivity and efficiency of teamwork and communication and improve the chance of lowering security issues. The findings of this study also contribute to the general body of knowledge about the effect of physical design on teamwork, collaborative communication, and security.

"Everything Happens in the Hallways": Exploring User Activity in the Corridors at Two Rehabilitation Units

OBJECTIVES

This research aimed to examine the role of the corridors in specialist inpatient rehabilitation units to inform future design of these spaces.

BACKGROUND

In healthcare settings, such as rehabilitation units, corridors have often been designed simply as spaces allowing movement between other locations. However, research suggests that corridors may be places where important social and care-related activities take place. How corridors are used and understood by patients and staff in inpatient rehabilitation settings is unclear, and a greater understanding of the role of corridors in these settings could help to inform more supportive design of these spaces.

METHODS

Independent observations of user activity were conducted at a major metropolitan inpatient spinal injury unit (SIU) and brain injury unit (BIU). Interviews were conducted with SIU patients ( n = 12), and focus groups were conducted with SIU staff ( n = 23), BIU patients ( n = 12), and BIU staff ( n = 10).

RESULTS

Results from the observations showed that the corridors were used frequently across the day, particularly by staff. Thematic analysis of staff and patient experiences found three key themes describing how corridors were used: (1) moving around, (2) delivery and experiences of quality care, and (3) a "spillover space."

CONCLUSIONS

Results demonstrate that corridors not only have an important role as connective spaces but are also used as flexible, multipurpose spaces for delivery of quality care and patient experiences. Future design should consider how these spaces can more deliberately support and contribute to patient and staff experiences of rehabilitation.

Integrating Lean Exploration Loops Into Healthcare Facility Design

PURPOSE

To explore how Lean can add value during the schematic phase of design through providing additional resources and support to project leadership and the architectural design team.

BACKGROUND

This case study-based research took place at one large academic hospital during design efforts of surgical tower to house 19 operating rooms (ORs) and support spaces including pre- and post-op, central processing and distribution, and materials management. Surgical services project leadership asked for Lean practitioners' support during the design process.

METHODS

Lean Exploration Loops (LELs) were conducted to generate evidence to support stakeholders, as they made important decisions about the new building design. The analyses conducted during LELs during the schematic phase were primarily conducted using express workouts (EWOs) and were focused on the flow of patients, staff, and family throughout the pavilion.

RESULTS

LELs resulted in recommendations for key design features (e.g., number of pre- and post-op bays per OR floor, location of doors, scrub sinks, stretcher alcoves, equipment storage, and sterile core areas). Two-sided pre- and post-op bays with an inner clinical workspace and an outer patient transport corridor were recommended. Communicating elevator and a centrally located stairwell for staff to alleviate stress on the main bank of elevators at peak usage times were also suggested.

CONCLUSIONS

We found Lean tools and methods to be of most value during schematic phase when focused on detailed process and layout analysis, while acknowledging the usefulness of focused EWOs to generate the evidence needed for the decision-making.